Medical Surgical Nursing Part 3

432 Pages·2013·10.15 MB·English

Medical Surgical Nursing
Part III

Dr. Nasser Abu-El-Noor

2013

0
Chapter 39
Management of Patients with Hepatic Disorders

Learning Objectives
 Identify the metabolic functions of the liver and the alterations in these
functions that occur with liver disease .
 Explain liver function tests and the clinical manifestations of liver dysfunction
in relation to pathophysiologic alterations of the liver .
 Relate jaundice, portal hypertension, ascites, varices, nutritional deficiencies,
and hepatic coma to pathophysiologic alterations of the liver .
 Describe the medical, surgical, and nursing management of patients with
esophageal varices .
 Compare the various types of hepatitis and their causes, prevention, clinical
manifestations, management, prognosis, and home health care needs .
 Use the nursing process as a framework for care of the patient with cirrhosis of
the liver .
 Compare the nonsurgical and surgical management of patients with cancer of
the liver .
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 Describe the postoperative nursing care of the patient undergoing liver
transplantation
Anatomic and Physiologic Overview

 The liver, the largest gland of the body (1.4-1.8kg), can be considered a
chemical factory that manufactures, stores, alters, and excretes a large number
of substances involved in metabolism .
 The location of the liver is essential in this function, because it receives
nutrient-rich blood directly from the gastrointestinal (GI) tract and then either
stores or transforms these nutrients into chemicals that are used elsewhere in the
body for metabolic needs .
 The liver is especially important in the regulation of glucose and protein
metabolism .
 The liver manufactures and secretes bile, which has a major role in the digestion
and absorption of fats in the GI tract. It removes waste products from the
bloodstream and secretes them into the bile .
 The bile produced by the liver is stored temporarily in the gallbladder until it is
needed for digestion, at which time the gallbladder empties and bile enters the
intestine

ANATOMY OF THE LIVER
 The liver is located behind the ribs in the upper right portion of the abdominal
cavity. It weighs about 1,500 g and is divided into four lobes .
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 A thin layer of connective tissue surrounds each lobe, extending into the lobe
itself and dividing the liver mass into small units called lobules
 The circulation of the blood into and out of the liver is of major importance in
its function. The blood that perfuses the liver comes from two sources.
 Approximately 75% of the blood supply comes from the portal vein, which
drains the GI tract and is rich in nutrients. The remainder of the blood supply
enters by way of the hepatic artery and is rich in oxygen. Terminal branches of
these two blood supplies join to form common capillary beds, which constitute
the sinusoids of the liver
 The sinusoids empty into a venule that occupies the center of each liver lobule
and is called the central vein. The central veins join to form the hepatic vein,
which constitutes the venous drainage from the liver and empties into the
inferior vena cava, close to the diaphragm. Thus, there are two sources of blood
flowing into the liver and only one exit pathway 10
 •In addition to hepatocytes, phagocytic cells belonging to reticuloendothelial
system are present in the liver. Other organs that contain reticuloendothelial
cells are the spleen, bone marrow, lymph nodes, and lungs. In the liver, these
cells are called Kupffer cells. Their main function is to engulf particulate matter
(such as bacteria) that enters the liver through the portal blood .

 The smallest bile ducts, called canaliculi, are located between the lobules of the
liver. The canaliculi receive secretions from the hepatocytes and carry them to
larger bile ducts, which eventually form the hepatic duct. The hepatic duct from
the liver and the cystic duct from the gallbladder join to form the common bile
duct, which empties into the small intestine. The sphincter of Oddi, located at
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the junction where the common bile duct enters the duodenum, controls the
flow of bile into the intestine.
FUNCTIONS OF THE LIVER
1-Glucose Metabolism
 After a meal, glucose is taken up from the portal venous blood by the liver and
converted into glycogen, which is stored in the hepatocytes .
 Subsequently, the glycogen is converted back to glucose and released as needed
into the bloodstream to maintain normal levels of blood glucose .
 Additional glucose can be synthesized by the liver through a process called
gluconeogenesis. For this process, the liver uses amino acids from protein
breakdown or lactate produced by exercising muscles .
2. Ammonia Conversion
 Use of amino acids from protein for gluconeogenesis results in the formation of
ammonia as a byproduct. The liver converts this metabolically generated
ammonia into urea .
 Ammonia produced by bacteria in the intestines is also removed from portal
blood for urea synthesis. In this way, the liver converts ammonia, a potential
toxin, into urea, a compound that can be excreted in the urine .
3. Protein Metabolism
 The liver synthesizes almost all of the plasma proteins (except gamma
globulin), including albumin, alpha and beta globulins, blood clotting factors,
specific transport proteins, and most of the plasma lipoproteins .
 Amino acids serve as the building blocks for protein synthesis .
 Vitamin K is required by the liver for synthesis of prothrombin and some of the
other clotting factors .
4. Fat Metabolism
 Fatty acids can be broken down for the production of energy and the production
of ketone bodies .
 Ketone bodies are small compounds that can enter the bloodstream and provide
a source of energy for muscles and other tissues .
 Breakdown of fatty acids into ketone bodies occurs primarily when the
availability of glucose for metabolism is limited, as during starvation or in
uncontrolled diabetes .
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 Fatty acids and their metabolic products are also used for the synthesis of
cholesterol, lecithin, lipoproteins, and other complex lipids .
5. Vitamin and Iron Storage
 Vitamins A, B, and D and several of the B-complex vitamins are stored in large
amounts in the liver .
 Iron and copper, are also stored in the liver .
 Because the liver is rich in these substances, liver extracts have been used for
therapy for a wide range of nutritional disorders .
7. Drug Metabolism
 The liver metabolizes many medications
 Metabolism generally results in loss of activity of the medication, although in
some cases activation of the medication may occur.
 One of the important pathways for medication metabolism involves conjugation
(binding) of the medication with a variety of compounds, such as glucuronic or
acetic acid, to form more soluble substances .
 The conjugated products may be excreted in the feces or urine, similar to
bilirubin excretion .
8. Bile Formation
 Bile is continuously formed by the hepatocytes and collected in the canaliculi
and bile ducts .
 It is composed mainly of water and electrolytes such as sodium, potassium,
calcium, chloride, and bicarbonate, and significant amounts of lecithin, fatty
acids, cholesterol, bilirubin, and bile salts .
 Bile is collected and stored in the gallbladder and is emptied into the intestine
when needed for digestion .
 Bile also serves as an aid to digestion through the emulsification of fats by bile
salts .
 Bile salts are synthesized by the hepatocytes from cholesterol. After conjugation
or binding with amino acids, they are excreted into the bile .
 The bile salts, together with cholesterol and lecithin, are required for
emulsification of fats in the intestine, which is necessary for efficient digestion
and absorption .
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 Bile salts are then reabsorbed, primarily in the distal ileum, into portal blood for
return to the liver and are again excreted into the bile.

9. Bilirubin Excretion
 Bilirubin is a pigment derived from the breakdown of hemoglobin by cells of
the reticuloendothelial system .
 Hepatocytes remove bilirubin from the blood and modify it to be more soluble
in aqueous solutions .
 The conjugated bilirubin is secreted by the hepatocytes into the adjacent bile
canaliculi and is eventually carried in the bile into the duodenum .
 In the small intestine, bilirubin is converted into urobilinogen, which is in part
excreted in the feces and in part absorbed through the intestinal mucosa into the
portal blood .
 Some of the urobilinogen enters the systemic circulation and is excreted by the
kidneys in the urine .
Gerontologic Considerations
 The most common change in the liver in the elderly is a decrease in its size and
weight, accompanied by a decrease in total hepatic blood flow. Results of liver
function tests do not normally change in the elderly; abnormal results in an
elderly patient indicate abnormal liver function and are not the result of the
aging process itself .
 The immune system is altered in the aged, and a less responsive immune system
may be responsible for the increased incidence and severity of hepatitis B in the
elderly and the increased incidence of liver abscesses secondary to decreased
phagocytosis by the Kupffer cells .
Age-Related Changes of the Hepatobiliary System
 Steady decrease in size and weight of the liver, particularly in women .
 Decrease in blood flow .
 Decrease in replacement/repair of liver cells after injury .
 Reduced drug metabolism .
 Rapid progression of hepatitis C infection and lower response rate to therapy .
 Decline in drug clearance capability .
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 Increased prevalence of gallstones .
 Decreased gallbladder contraction after a meal .
 More severe complications of biliary tract disease.

ASSESSMENT HEALTH HISTORY
 If liver function test results are abnormal, the patient may need to be evaluated
for liver disease. So look if the client :
• Was exposed to hepatotoxic substances or infectious agents .
• Patient‘s occupational, recreational, and travel nhistory may assist in
identifying exposure to hepatotoxins
• Patient‘s history of alcohol and drug use
• Lifestyle behaviors (Injectable drug use, sexual practices )
• Current and past medical conditions, previous blood transfusion .
PHYSICAL EXAMINATION
 Assess the patient for pallor, jaundice (skin, mucosa, and sclerae), and the
extremities are assessed for muscle atrophy, edema, and skin excoriation
secondary to scratching .
 Observe the skin for petechiae or ecchymotic areas (bruises), spider angiomas,
and palmar erythema .
 Assess male patient for unilateral or bilateral gynecomastia and testicular
atrophy due to endocrine changes .
 Asses patient‘s cognitive status (recall, memory, abstract thinking) and
neurologic status are assessed .
 Palpate abdomen to assess liver size and to detect any tenderness over the liver.
A palpable liver presents as a firm, sharp edge with a smooth surface
 Tenderness of the liver implies recent acute enlargement with consequent
stretching of the liver capsule .
 Enlargement of the liver is an abnormal finding requiring evaluation .

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Diagnostic Evaluation
Liver Function Tests
 More than 70% of the parenchyma of the liver may be damaged before liver
function test results become abnormal .
1. Serum enzyme activity (ie, alkaline phosphatase, lactic dehydrogenase, serum
aminotransferases )
2. Serum concentrations of proteins (albumin and globulins ,)
3. Bilirubin, ammonia, clotting factors, and lipids .
4. Serum aminotransferases (also called transaminases) are sensitive indicators of
injury to the liver cells and are useful in detecting acute liver disease such as
hepatitis .
A. Alanine aminotransferase (ALT) (formerly called serum glutamic-pyruvic
transaminase [SGPT]) (10-40 U/L )
B. Aspartate aminotransferase (AST) (formerly called serum glutamic-
oxaloacetic transaminase [SGOT]) (5-35 U/L )
C. Gamma glutamyl transferase (GGT) (also called G-glutamyl transpeptidase)
(10-48 U/L )
D. .Lactic Dehydirgenase (LDH) (100-200 U/L).
These studies measure the ability of the liver to conjugate and excrete bilirubin. Results
are abnormal in liver and biliary tract disease and are associated with jaundice
clinically.
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Pigment Studies Normal
1. Serum bilirubin, direct 1. 0–0.3 mg/dL (0–5.1 µmol/L)
2. Serum bilirubin,total 2. 0–0.9 mg/dL (1.7–20.5 µmol/L)
3. Urine bilirubin 3. 0(0)
4. Urine urobilinogen 4. 0.05–2.5 mg/24 h (0.09–4.23
µmol/24 h)
5. Fecal urobilinogen (infrequently used) 5. 40–200 mg/24 h (0.068–0.34
mmol/24 h)

CLINICAL FUNCTIONS
 Proteins are manufactured by the liver. Their levels may be affected in a variety
of liver impairments
• Albumin: Cirrhosis
Chronic hepatitis
Edema, ascites
• Globulin: Cirrhosis
Liver disease
Chronic obstructive jaundice
Viral hepatitis
Test Normal
Protein Studies
•Total serum protein 7.0–7.5 g/dL (70–75 g/L)
•Serum albumin 4.0–5.5 g/dL (40–55 g/L)
•Serum globulin 1.7–3.3 g/dL (17–33 g/L)
Serum protein electrophoresis
•Albumin 4.0 –5.5 g/dL (40–55 g/L)
•α1-Globulin 0.15–0.25 g/dL (1.5–2.5 g/L)
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